Jesus Christ paid for your freedom; He came to destroy the works of the Devil 1Jn 3:8.

When going through this list, please pray that the Holy Spirit will reveal the truth. God resists the proud, but gives grace unto the humble. Please be honest, you have our full confidentiality, but light needs to expose ALL darkness. If you keep even a little bit to yourself, full freedom is not possible. Joshua 7 Achan kept to himself a few accursed objects and caused Israel to be defeated and 36 men died. This work is 2/3 of the process; casting out demons is the easy part!

Dealing with a lot of people and each person has 4 different names, it is hard to keep track sometimes. First Name: Skype Name: Email Address: Youtube Channel (if applicable): Age: The purpose of this form is to help determine possible entry ways for evil spirits...obviously, generational/ancestral permission as forewarned in Exodus 20:5 is a possibility in anyone's life. There are ancestors in your history that could have passed a spirit on to you, likely, you only know about your parents and each of their two parents. 1. Please give any information that the Holy Spirit brings to your mind. Examples would be involvement with the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, involvement in groups such as Free-Masonry, Illuminati, Shriners, Eastern Star, Odd Fellows, Rainbow Girls, and Rebecca Lodge etc. Aware of ancestor involvement in any of these?: If Yes, explain: Yes No

Does any of your siblings struggle with the same addictions you and your parents struggle with? What are they? Note: It is not necessary to give the nitty-gritty details. Rely on the Holy Spirit. 2. From birth and your early childhood: Trauma during pregnancy by your mom or dad, divorce, words of "We shouldn't be having this child", spent time in incubator, etc.? If Yes, explain:

3. Early childhood fears, injuries, nightmares, see things in your room, felt evil presence, supernatural attacks? If Yes, explain:

4. Any sexual abuse, molestation or sexual embarrassment? If Yes, explain:

4A. Have you ever been diagnosed with Multiple Personality Disorder or Dissociative Identity Disorder? Satanic Ritual Abuse? Do you lose blocks of time? Do you have memories that are not your own? Do your friends or family comment on the extreme personality changes in you? 4B. Have you forgiven your abusers? 5. Spoken words from parents, or others that were condemnation: "You're fat, you're stupid, you'll never amount to anything, you always mess up, I don't know why we had you. You can't be in our group, etc embarrassing or humiliating experiences at school or from school teacher? If Yes, explain:

6. Any physical abuse from parents or others? If Yes, explain: 6A. Have you forgiven them? 7. Involvement (however innocently it may have been) with Ouija Boards, New Age, Reiki, spirit guides, power animals, chi, levitation games, sances, fortune tellers, tarot cards, astrology, Santeria, Voodoo, horoscopes, fascination with books about magic or occult, psychic seers, Harry Potter, demonic video games, Role playing games that involve magic, been in a cult, etc.?: If Yes, explain:

8. Please list accidents or injuries that come to your mind as being frightening and still haunts you:

9. Please list surgeries and approximate age:

10. Movies or TV programs that were particularly frightening to you, or specific scenes that plague you even now:

11. Have you participated in pre-marital sex?: Periods of immorality? If Yes, specify ages:

Yes

No

12. Drinking and/or drug use? Any supernatural experiences while high? If Yes, explain and specify ages:

13. What do you fear? Or what triggers fear (lie, circumstance)? Please list all:

14. What do you think may be the areas of demonic influence in your life?

15. Problems in home? If Yes, explain:

16. Are your parents divorced?: If Yes, how old were you?

Yes

No

17. Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.? If Yes, explain:

18. Exposed to pornography?:

Yes

No

If Yes, how old were you? Did an adult expose you to pornography? Please answer the following questions as they apply to your life: 19. Homosexual tendencies? 20. Participated in college fraternities, sororities, or secret societies? 21. Feelings of guilt and shame? 22. Hopelessness or feelings of gloom? 23. Fatigue without medical reason? 24. Abortion or caused girl to get one? 25. Difficulty in forgiving, to include yourself or God? 26. Is there bitterness, anger, or unforgiveness? 27. If so, can you forgive? 28. Do you hate yourself? 29. Have you suffered from self harm? 30. Are you greedy, or never content, always competing w/ the Jones? 31. Do you feel rejected? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No

32. Do you have any objects in your home or possession that relate to ungodliness or cults, this would include new age religions, such as books about eastern deities, crystals, heavy metal music, Mother Mary (or any idol) Native American artifacts, wiccan, etc.? Also, frogs, owls, dragons, snakes, and scorpions are demons in the Bible: Yes If Yes, can you give examples? Have you destroyed them yet? No

33. Ever "felt" a presence in the room? If Yes, has it been recently? Yes, please explain, was there a message?:

Yes Yes

No No

34. Do you hear voices? Yes No Can you identify what happened in your life when the voices were

introduced or became stronger? What do the voices say? 35. Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma, hypertension, migraines, lingering pain from accident, etc.)? Please list any and all physical ailments: Yes No

36. Do you have inexplicable pain...no medical explanation for it? If Yes, please explain if not mentioned in #35: 37. Please list all Pharmaceutical and/or street drugs you currently are using and for what reason.

Yes

No

38. Has there been a death of someone close to you? If so, whom?

Yes

No

After the death, did problems or addictions in your life get worse?

39. Do you feel like you have any eating disorders? If Yes, do you know when they began? What happened at that time? 40. Do you suffer from sleep disorders? 41. Any other medically defined disorder? If Yes, please explain: 42. Have you ever been angry with God?

Yes

No

Yes Yes

No No

Yes If Yes, please explain why:

No

43. Did you have an imaginary friend(s) as a child?

Yes

No

If Yes, what were their names? 44. When attending Church/other ministries do you have "foul" thoughts, jealousies or other mental harassment? 45. Do you have difficulty retaining God's Word? 46. Difficulty in reading it? 47. Do you have suicidal thoughts? 48. Do you have a plan on how you are going to kill yourself? 49. Were you ever diagnosed with a learning disability i.e. (ADD, ADHD, Dyslexia), etc? 50. Do you have a fear of death? 51. Do you have any addictions or compulsions? What are they? Yes Yes Yes Yes Yes No No No No No

Yes Yes Yes Yes Yes Yes

No No No No No No

52. Do you feel inferior? 53. Do you fear of losing your mind? 54. Anxiety or panic attacks? If Yes, what is the thought that starts the attack? Have you been in combat or to a war zone? 55. Do you feel incredible loneliness? 56. Are you plagued with doubt and unbelief? 57. Do you believe you can be free of your demons/ addictions/ compulsions/diseases/mental disorders?? 58. Do you hate silence; always have the TV/Radio on? 59. Do you have obsessive thoughts? 60. Blasphemous thoughts? 61. Compulsive thoughts? 62. Lustful thoughts? 63. Are you prideful? If so, are you able to be fully honest in this questionnaire? 64. Are you a perfectionist? 65. Are you isolated, no one understands?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No

66. Do you feel the need to be in control, things are always out of order, worry, worry, worry? 67. Are you rebellious? 68. Insecurity? (Scale of 1-10 with 10 being worst)? Please explain:

Yes Yes

No No

69. Here are a few more overt symptoms of demonic attack. This list is not comprehensive; it is very, very, very rare for a Christian to not have any demons before deliverance. Please check any symptom that applies to you:
1. 2. 3. 4. 5. 6. 7. 8.

A compulsive desire to blaspheme God. A revulsion against the Bible, including a desire to tear it up or destroy it. Compulsive thoughts of suicide or murder. Deep feelings of bitterness and hatred toward others without reason: Jews, other races, the church, strong Christian leaders. Supernatural knowledge on how to tear people down. Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting by the tongue, or you feel like you are helping but your tongue only hurts. Terrifying feelings of guilt/shame even after honest confession is made to the Lord. Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason.
A. B. C. D. E.

Choking sensations. Pains which seem to move around and for which there is no medical cause. Feelings of tightness about the head or eyes. Dizziness, blackouts, or fainting seizures. Sexual stimulus without explanation

9. 10. 11. 12.

Deep depression and despondency. Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility. Terrifying doubt of one's salvation even though they once knew the joy of salvation. Panic attacks or other fears that are terrifying.

13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

Dreams or nightmares that are of a horrific nature and often ...recurring. Clairvoyant dreams that come true may be demonic when not living holy. Abnormal or perverted sexual desires for same sex, animals, objects or children. Satanic Ritual Abuse. Have to control others for their own good or for your entertainment. Most compulsions, obsessions and addictions. Rebellion and hatred for authority or those just wanting to help. Bizarre terrifying thoughts/voices that come from nowhere and cant control them. Fascination with the occult, (to include movies, video games, research, etc). Involvement in criminal activity. Extremely low self-image, self-hatred, cutting (unworthy, a failure, no good). Constant confusion in thinking (sometimes great difficulty in remembering things). Inability to believe (even when the person wants to). Mocking and blasphemous thoughts against preaching/teaching of the Word of God. Perceptual distortions - perceiving anger, hostility, in others when it doesn't really exist - seeing only judgment in the scriptures. Even after confession, dont feel holy or forgiven until days after. Need punishment. Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.). Hatred and bitterness toward others for no justifiable reason (always looking for a fight). Tremendous hostility or fear when encountering deliverance workers. Feelings of being watched or sensing an evil presence. Diagnosed with Post Traumatic Stress Disorder or PTSD Irrational fears - panic attacks - phobias. Animals fear you for no reason. Marks, symbols or scratches appear on your body for no reason. Desire to do what is right (inability to carry it out despite true repentance). Sudden personality and attitude changes (severe contrasts - appears schizophrenic) Bipolar disorder. A strong aversion toward scripture reading and prayer (especially one on one). A dark countenance (steely or hollow look in eyes - contraction of the pupils sometimes facial features contort or change - often an inability to look at you directly. Lying, exaggerating, or stealing compulsively (often wondering why). Drug abuse (especially when there are demonic hallucinations).

42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60.

Eating obsessions - bulimia, anorexia nervosa. Compulsive sexual sins, (especially perversions). Irrational laughter or crying. Bully, through Manipulation, Intimidation or Domination. Sudden speaking of a language not previously known (not gift of tongues) (often an ethnic language of ancestors). Reactions to the name and blood of Jesus Christ (verbally or through body language). Extreme restlessness (especially in a spiritual environment). Vulgar language and actions. Self humiliation. Loss of time (from minutes to hours - ending up someplace, not knowing how you got there - regularly doing things of which there is no memory). Extreme sleepiness around spiritual things. Demonstration of extraordinary abilities (either ESP or Telekinesis). Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain). Voice - refers to him/her in the third person. Supernatural experiences - haunting, movement or disappearance of objects, and other strange manifestations. Seizures (too long and/or too regular). Pain (without justifiable explanation - especially in head and/or stomach). Blackouts. Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, and various pains). Sudden interference with bodily functions (temporary) - buzzing in ears, inability to speak or hear, sudden severe headache, hypersensitivity in hearing or touch, sudden chills or overwhelming heat in body, numbness in arms or legs, temporary paralysis.

Judgmental, religious, prideful, incessant need to tell others they are wrong and you are right. When in doubt ... cast them out!
61.

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